Medical Centre

The NHS is now rolling out booster doses of Covid-19 vaccines. Today, the JCVI recommended that all adults in the UK should receive a booster. Why do we need these boosters?

The number of Covid-19 cases in the UK is currently around 40,000 per day. This is amongst the highest rate of infection of any country in the world and higher than many of our Western European neighbours. Vaccines are protecting us and without them, we would be seeing many more people who are seriously ill. However, some of these infections will still lead to a serious illness and death, even in people who have received two doses of a Covid-19 vaccine as no vaccine is 100% effective.

We know that the protection provided by Covid-19 vaccines can weaken over time – particularly in the elderly or in those people with weak immune systems. Research from the UK and elsewhere shows that a booster (third) dose of a vaccine improves your immunity to Covid-19 and reduces your risk of a serious illness that may lead to hospitalisation or death. Some people with medical conditions or who are taking drugs that weaken their immune system will need four doses of vaccine to give them maximum protection.

The rollout of the NHS booster programme has been slower than we would have liked. We want as many people as possible to receive boosters before the onset of winter when pressures on the NHS increase. Because most Covid-19 restrictions in England ended in July, many people may think the pandemic is largely over and so do not think they need another vaccination. Some people may also lack confidence in vaccines or be concerned about side effects. Others may be struggling to get an appointment at a vaccine clinic that is convenient for them to attend.

To help people get their booster vaccines, the NHS needs to make it as easy as possible for people to book and attend their appointments. The NHS can do this by ensuring there are local sites offering boosters so that people don’t have to travel far to get one. The sites also need to have convenient opening hours (such as being open in the evenings and at weekends) that allow people who are working to attend easily. There also needs to be sufficient capacity in the vaccination programme to allow as many people as possible to be vaccinated before Christmas.

It’s also important for the NHS to explain clearly why we need boosters, and remind people about the safety and effectiveness of vaccines. We now have data from many millions of people across the world to show how well Covid-19 vaccines work and how safe they are. The UK has led the world on much of this research thanks to the data collected by our NHS.

The people being targeted for boosters are those at highest risk of serious illness and death from a Covid-19 infection. This includes people aged 40 and over, and people under 50 with medical conditions that put them at higher risk. NHS staff, people who live and work in care homes, and people who are the main carer of someone at high-risk are also being invited for boosters. The NHS will now be extending the booster programme to all adults based on the advice issued today by the JCVI.

If people don’t attend for their boosters, they will increase their risk of catching Covid-19 and having a more serious illness. This will lead to more cases of Covid-19 and increased pressures on the NHS during the winter. The number of deaths from Covid-19 will also increase.

This then may require the government to bring back some Covid-19 restrictions; and if the situation gets very bad, it may require a further infection control measures. This is something we want to avoid because of all the problems that lockdowns cause. We all want a more normal way of life and don’t wish to see a repeat of last year when Christmas gatherings were not possible because of the Covid-19 rules that were in place at the time.

The good news is that our vaccines continue to work well against new virus variants when people are fully vaccinated. If, however, people are not fully protected by vaccination, new variants like Omicron may spread further and eventually lead to other variants arising against which current vaccines are less effective.

Covid-19 vaccines are safe and very effective. By getting a booster, you are protecting yourself and the other people you live and work with. You are also reducing the need for the government to introduce new Covid-19 restrictions this winter. So please go out and get your booster vaccine as soon as you can.

A version of this article was first published in The Sun.

Read The JCVI is recommending booster Covid-19 vaccines for all adults – why is this essential for the UK’s pandemic response? in full

The NHS is now rolling out booster doses of Covid-19 vaccines. Why do we need these boosters and who can receive them?

The number of Covid-19 cases in the UK is around 40,000 per day. This is amongst the highest rate of infection of any country in the world and higher than all our Western European neighbours. Vaccines are protecting us and without them, we would be seeing many more people who are seriously ill. However, some of these infections will still lead to a serious illness and death, even in people who have received two doses of a Covid-19 vaccine as no vaccine is 100% effective.

We know that the protection provided by Covid-19 vaccines can weaken over time – particularly in the elderly or in those people with weak immune systems. Research from other countries shows that a booster (third) dose of a vaccine improves your immunity to Covid-19 and reduces your risk of a serious illness that may lead to hospitalisation or death. Some people with medical conditions or who are taking drugs that weaken their immune system will need four doses of vaccine to give them maximum protection.

The rollout of the NHS booster programme has been slower than we would have liked. We want as many people as possible to receive boosters before the onset of winter when pressures on the NHS increase. Because most Covid-19 restrictions in England ended in July, many people may think the pandemic is largely over and so do not think they need another vaccination. Some people may also lack confidence in vaccines or be concerned about side effects. Others may be struggling to get an appointment at a vaccine clinic that is convenient for them to attend.

To help people get their booster vaccines, the NHS needs to make it as easy as possible for people to book and attend their appointments. The NHS can do this by ensuring there are local sites offering boosters so that people don’t have to travel far to get one. The sites also need to have convenient opening hours (such as being open in the evenings and at weekends) that allow people who are working to attend easily.

It’s also important for the NHS to explain clearly why we need boosters, and remind people about the safety and effectiveness of vaccines. We now have data from many millions of people across the world to show how well Covid-19 vaccines work and how safe they are. The UK has led the world on much of this research thanks to the data collected by our NHS.

The people being targeted for boosters are those at highest risk of serious illness and death from a Covid-19 infection. This includes people aged 50 and over, and people under 50 with medical conditions that put them at higher risk. NHS staff, people who live and work in care homes, and people who are the main carer of someone at high-risk are also being invited for boosters.

If people don’t attend for their boosters, they will increase their risk of catching Covid-19 and having a more serious illness. This will lead to more cases of Covid-19 and increased pressures on the NHS during the winter. The number of deaths from Covid-19 will also increase.

This then may require the government to bring back some Covid-19 restrictions; and if the situation gets very bad, it may require a further lockdown. This is something we want to avoid because of all the problems that lockdowns cause. We all want a more normal way of life and don’t wish to see a repeat of last year when Christmas gatherings were not possible because of the Covid-19 rules that were in place at the time.

A high take-up of boosters will also reduce the chances of new virus mutations from developing. This year, we have seen the rapid spread of the delta variant of the SARS-CoV-2 virus across the world, including in the UK. Recently, a new version of the delta variant, the AY.4.2 subvariant, has been detected in the UK. This variant is causing concern because it may be more infectious than the original delta variant.

The good news is that our vaccines continue to work well against new virus variants when people are fully vaccinated. If, however, people are not fully protected by vaccination, new variants like AY.4.2 may spread and eventually lead to other variants arising against which current vaccines are less effective.

Covid-19 vaccines are safe and very effective. By getting a booster, you are protecting yourself and the other people you live and work with. You are also reducing the need for the government to introduce new Covid-19 restrictions this winter. So please go out and get your booster vaccine as soon as you can.

A version of this article was first published in The Sun.

On 15 November 2021, the JCVI announced that people aged 40-49 would also be eligible for booster doses of a Covid-19 vaccine.

Read Covid-19 vaccine boosters: Why they are important in full

The NHS is now rolling out booster doses of Covid-19 vaccines and flu jabs.

The number of Covid-19 cases in the UK remains very high. Vaccines are protecting us and without them, we would be seeing many more people who are seriously ill.

However, no vaccine is 100% effective. Some Covid-19 infections will still lead to a serious illness, even in people who have received two doses of vaccine. Flu will also be a threat this winter.

We know that the protection provided by Covid-19 vaccines can weaken over time – particularly in the elderly or in people with medical problems. A booster (third) dose of a vaccine improves your immunity and reduces your risk of a serious illness.

We want as many people as possible to receive Covid-19 boosters and flu jabs before the onset of winter when pressures on the NHS increase.

The people being targeted for boosters are those at highest risk of serious illness and death from a Covid-19 infection. This includes people aged 50 and over, and people under 50 with certain medical conditions. NHS staff, people who live and work in care homes, and people who are the main carer of someone at high-risk are also being invited for boosters. These groups are also eligible for a flu jab.

If people don’t attend for their vaccinations this will lead to more cases of Covid-19 and flu, and increased pressures on the NHS during the winter. The number of deaths will also increase. This then may require the government to bring back some Covid-19 restrictions.

By getting a Covid-19 booster and a flu jab, you are protecting yourself and the other people you live and work with. So please go out and get your vaccinations as soon as you can.

Read Why you should get your Covid-19 booster and flu vaccine in full

On 1^st September 2021 the JCVI  recommended that certain patients aged 12 and over, who were thought to be immuno-suppressed (through disease or medication) around the time of their first two doses of Covid-19 vaccine, should be offered a third primary dose 8 weeks after their second dose. There has been considerable confusion about these third primary doses as they are different from the booster doses that many people who are now over 6 months after their second dose are being offered. Many patients have reported they have been unable to obtain their third primary dose; or have only obtained after a lengthy dialogue with NHS clinicians and managers.

Here are the steps that could be followed to safely implement the third primary vaccine dose programme for immunocompromised patients in England’s NHS.

1. Identify your target population. This is an essential first step in any vaccination programme (or in any public health programme). Identifying the target population requires searching NHS medical records held by hospitals and general practices.
2. Clinical diagnoses (such as renal transplant) have to be turned into lists of clinical codes. This requires collaboration between hospital doctors, GPs, other health professionals and health informatics specialists to produce the code lists based on the ICD-10, SNOMED and Read clinical codes that are used by NHS organisations.
3. Patients need to be identified who were prescribed medications around the time of their first two doses of Covid-19 vaccine that have been identified by the JCVI and specialist groups as possibly leading to a weaker response to their vaccinations. This might not be possible for GPs to do if they did not prescribe the medication themselves as is the case for many specialised drugs used for these patients.
4. There needs to be adequate consultation with organisation such as NHS Digital, general practices, primary care networks, specialist medical societies, and patient organisations (for example, Versus Arthritis, Blood Cancer UK, Crohn’s & Colitis UK and Kidney Care UK amongst others).
5. Once an agreed form of words and a unified approach have been reached, there should be a clear public health announcement via reputable sources, and NHS web pages available with clear easy to understand information and FAQs for clinicians, patient support organisations and the public. Clinicians and their teams should ideally be made aware of any announcements from NHS England before the public so that they are able to answer queries from patients, parents and carers.
6. Those working at NHS 119, vaccine sites or the national covid-19 vaccine call centres must be fully briefed and updated on significant changes before any announcements are made, so that patients calling with queries or to book their Third Primary Doses are not met with a confused response and a lack of a clear process on how to access their vaccines (which damages public trust and confidence, and increases vaccine hesitancy).
7. Programmes that use clinical codes to search NHS medical records have to be written. These require testing and debugging to make sure they work correctly on each different clinical record system used by the NHS. The NHS does not have a unified electronic medical record system and individual NHS Trusts and general practices will have different systems. These programmes need to be written centrally wherever possible to prevent local areas producing their own versions that may differ from each other and thus not identify patients correctly. This is more straightforward for general practices than hospitals because most general practices mainly use of one two electronic medical record systems (EMIS or SystmOne). The situation is more complex in NHS hospitals because of the many different IT systems used.
8. Once the programmes are written, they need to be run by local NHS teams as it seems that NHS England is not yet able to run these searches centrally for all of England. In the case of general practices, local CCGs or GP Federations should be able to run the searches to identify patients. Hospitals will also need to run searches to identify eligible patients. The NHS should also make use of National Disease Registers, such as the NHS Blood and Transplant registry, for patient identification wherever possible.
9. The list of patients generated by the programmes have to be cleaned to remove duplicates and any patients identified in error. Patients who may be unsuitable for vaccination such as the extremely frail or terminally ill need to be removed from the lists. Local NHS teams also need to consider how they approach patients who may have previously refused vaccination.
10. Patients then need to be contacted about the vaccinations. Most general practices are no longer involved in the Covid-19 vaccination programme. These invitations therefore need to come from organisations that are offering Covid-19 vaccines. This might include hospital clinics, NHS vaccine centres, or GP-led vaccine hubs in areas where GPs are still offering Covid-19 vaccines.
11. IT systems that record Covid-19 vaccinations (such as Pinnacle) need to be able to record the third primary dose correctly; so that it is not recorded as a standard booster dose or as another first or second dose. This ensures the patient’s vaccination status is accurate, that audits can be done accurately and that recalls can be generated for a booster in 6 months. Details of the vaccination also needs to be uploaded correctly into the patients’ usual electronic health record.
12. The NHS app needs to correctly display that this is indeed a third primary dose, and that the patient is fully vaccinated; and IT systems need to ensure that the patients can then also be invited for their booster dose (effectively, a fourth vaccine dose for this special group of patients) in due course (typically likely to be six months after the third primary dose). A system for recording vaccines given abroad should also be made available.
13. Please remember that in most parts of England, your general practice cannot offer you a Covid-19 vaccine or book you an appointment for one. In these circumstances, NHS 119 or your local NHS Covid-19 vaccine centre need to do this. To make access to vaccinations easier for patients, the NHS should ensure that a large number of locations are offering vaccinations so that patients can receive these close to home and do not have to travel long distances. Arrangements for vaccination also need to be made for the residents of care homes and for people who are housebound.
14. NHS medical records are not always accurate or up to date. Each local area needs to have a named person who patients can contact if they feel they have been missed off the list incorrectly; or to help patients who continue to have any difficulties booking appointments.
15. In order to provide a booster (fourth) dose for this group after six months, around April 2022, NHS IT systems need to be accurate and record third primary doses correctly and not as booster doses. This will ensure that this vulnerable group of patients do not experience further difficulties or delays in booking these appointments.

All these steps could have been better planned and communicated by NHS England; which would have made the process clearer for frontline NHS staff; as well as making it easier and less stressful for patients to receive their third primary Covid-19 vaccine dose. A well-planned and implemented vaccine programme maintains confidence in the vaccine programme which may reduce vaccine hesitancy, and helps patients and clinicians alike, improving vaccine uptake and reducing pressures on the NHS. It is essential that the problems experienced by immunocompromised patients in accessing their third primary Covid-19 vaccine doses are not repeated, appropriate lessons learned and steps taken by NHS England to ensure accurate recording of vaccinations and recall for future vaccinations for our most vulnerable patients.

Azeem Majeed, Professor of Primary Care and Public Health, Imperial College London, 

Simon Hodes, NHS GP Partner, Watford, UK and private general practitioner at the Cleveland Clinic London.

Fiona Loud, Policy Director, Kidney Care UK, Twitter

Liz Lightstone, Professor of Renal Medicine, Imperial College London, Twitter

This article was first published in BMJ Opinion.

Read Setting up a Covid-19 vaccination programme for immunocompromised patients in full

How a society treats its most vulnerable is always the measure of its humanity is a well-known quote often attributed to Mahatma Gandhi. With the “levelling up” agenda being quoted widely by the UK government, and the effects of pre-existing health inequalities never more exposed than by the covid-19 pandemic, we all need to focus on the health of the most vulnerable in society. Our highest risk patients, and their household members, were rightly prioritised for covid-19 vaccination at the start of the rollout programme in December 2020.

Early in the pandemic, the UK government recognised that certain patients with complex medical conditions, or who were immuno-suppressed through disease or medication, would be most at risk from the complications of covid-19. These patients were advised to take careful infection control precautions, and were classed as clinically extremely vulnerable” (CEV). Among the advice given to them was to “shield” and to facilitate this, they were added to a “Shielding Patients List” (SPL) at their GP practices. Despite GP practices having robust disease registers and arranging seasonal flu vaccine recalls annually for mostly similar patients, NHS England decided to create centrally generated lists for CEV, and sent out letters to these patients.

Unfortunately, NHS Digital wrote to many patients who probably should not have been included as CEV (for example those with a history of glandular fever; or with long resolved and fully treated cancers in full remission), and also failed to include many patients who should have been classed as CEV. At the time, a survey by Pulse reported that after assessing the list of shielded patients provided by NHS England, on average practices had to remove 30 patients from the list, while adding 53 patients who had been missed off.

GP teams nationwide spent many hours scrutinising these lists, using their electronic notes, disease registers, and personal patient knowledge. The list of CEV patients needed to be as accurate as possible to try to ensure that the most vulnerable were protected, pending the arrival of covid-19 vaccines.

The importance of the accuracy of these lists cannot be overemphasised. These patients were offered extra support from the government, and local volunteers such as regular check-up calls from social prescribers at GP practices and both the patients and their household members were prioritised for vaccines. The social and mental health impact of shielding has also been noted in practice and widely reported. When the Joint Committee on Vaccination and Immunisation (JCVI) announced the hierarchy of priority groups for vaccination, there was much debate about how high up the priority list CEV patients should be, with many surprised that they were left to be sixth in line, with priority for vaccination largely being determined by factors such as residential setting, health and social care occupation, and age.

We are now offering covid-19 vaccine boosters for many people who are over six months after their second dose. The JCVI also announced on 1 September 2021 that certain patients aged 12 and over, who were immuno-suppressed (through disease or medication) around the time of their first two doses, should be offered a third primary dose after eight weeks from their second dose. Once again, as seems to be a recurring theme throughout the pandemic, this process has been poorly announced with the media reporting it before healthcare professionals were instructed about the process; and without a clear plan for implementing the programme.

Our most vulnerable and naturally anxious patients are confused about who should be recalling them for a third primary dose, whether or not they will be given a booster (in effect their fourth vaccine) six months later, and where to access their vaccines. Kidney Care UK for example has been deluged with enquiries from patients, many of whom have tried calling the national NHS 119 helpline to find that the staff there are often unaware of the process for arranging third primary doses. Although the JCVI wrote to specialists on 2 September 2021, it clearly takes time to review notes, run searches, and contact patients, with many patients now contacting their GP practices for support and advice. Furthermore, many of these immune-suppressed patients may receive their medication from hospital clinics, and thus might not easily show up on medication searches in their general practices.

To add further complications, the software used (called Pinnacle) to record covid-19 vaccines is not yet able to recognise a third primary dose, so they are currently being recorded as boosters, which is technically not correct. This will make any audits of vaccine uptake in this group extremely challenging, and may cause confusion in the future. In addition, patients are reporting that their third primary doses are not displayed correctly on their NHS app, presumably for the same reason. Once again, this highlights the need for joined up thinking before rolling out plans. It is worth noting that GPs add seasonal flu vaccines on our fully electronic patient records (which are later uploaded to Pinnacle), but the covid vaccines have to be added on Pinnacle only (which is later uploaded to GP-held electronic medical records and the NHS app). This is the reverse of what we would expect and is once again an example of NHS staff being forced to adapt to IT systems rather than the IT systems being designed to support NHS staff in their day-to-day work.

The government must look at how they communicate with both the public and professionals to ensure that our ongoing covid-19 vaccination programme is fit for purpose, and maintains the trust of the public to ensure high take up and prevent vaccine hesitancy. Unfortunately, after a promising start, the UK has slipped down the covid-19 vaccination league tables, and we are becoming an international covid-19 hotspot because of our high infection rates. The covid-19 vaccination programme has allowed us to come out of lockdown, and its ongoing success will depend on public confidence and effective messaging from the centre. As we enter the winter, with many other non covid-19 seasonal infections already in circulation, it is crucial that we try to protect our most vulnerable in society by making our vaccination programme as easy as possible for patients to access and navigate.

Simon Hodes, GP Partner Watford, Twitter: @DrSimonHodes

Azeem Majeed, Professor of Primary Care and Public Health, Department of Primary Care & Public Health, Imperial College London. Twitter @Azeem_Majeed

This article was first published in BMJ Opinion.

Read Covid-19 vaccines: patients left confused over rollout of third primary doses in full